Monitoring obstetric services: putting the UN guidelines into practice in Malawi. I: developing the system

The UNICEF/WHO/ UNFPA "Guidelines for Monitoring the Availability and Use of Obstetric Services" was published in 1997 as a guide for implementing process indicators. The Malawi Safe Motherhood Project covers 5 million people and was the first large project to introduce the new indicators as part of a routine monitoring system. A rigorous process of needs assessment, tools development, operations research, field testing and training was conducted. It was necessary to reach agreement on locally appropriate standard definitions of obstetric emergencies, reporting formats and catchment populations. Underreporting of emergencies, misreporting of maternal deaths and double counting of referrals were minimized by improving recording tools. Time, cost, political and technical inputs are important considerations--in Malawi, the system took 1 year to set up at a cost of $100 000. Developing a routine monitoring system to obtain data for the process indicators is feasible, but requires adaptation of the cross-sectional evaluation methods described in the UN Guidelines.